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Directions: Use the “TAB” key to move through this form. Forward completed form to your Payroll Specialist or cbizbenefitsteam@. Confirm your deferral on your paycheck.Plan Contact InformationOptum Bank800-791-9361Group #188335Employee InformationClick here to enter text.Click here to enter text.Click here to enter text.Last NameFirst NameMiddle InitialClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Street AddressCityStateZip CodeXXX-XX-Click here to enter text.Click here to enter a date.SSN (Last four digits)Date of BirthEmployee Pay Period:?Weekly (52)?Monthly (12)?Semi-Monthly (24)Maximum HSA Contributions Per Calendar YearCalendar YearTierIRS Maximum Contribution55+ Catch-up Contribution*Employee Maximum with 55+ Catch-up2021Individual Coverage$3,600Up to $1,000$4,600Family Coverage$7,200Up to $1,000$8,200Every year, the IRS sets maximum contribution limits for health savings accounts (HSAs). Failure to observe these limits may result in tax penalties. Since your contribution limits may be specific to your circumstances, we recommend you contact a Tax Advisor to verify your limits. Please read any information you receive from your HSA Administrator carefully as opening an account is an agreement between you and the bank, and there may be fees associated with this account that are the responsibility of the account holder.Employee ElectionOptum Bank Election:?New Year Election?Change Request?New Acct. Request?Stop RequestPayroll Deduction InformationEnter your election including 55+ Catchup:Effective Date of Election:Click here to enter a date.55+ Catchup: Personal age 55 or older are entitled to an additional annual catch-up contribution of up to $1,000.Please check the box below if you are (or will be turning) 55+ years of age in 2021 AND are electing to make an additional catch-up contribution in 2021.Per Pay Period Deduction Amount:$Click here to enter text.(Required)Annual Goal Amount:$Click here to enter text.(Required) ? I qualify for, and have included the 55+ catch-up contribution in my Annual Goal ElectionsConfirmation of ElectionI have read, understand, and agree to the following:I authorize a pre-tax deduction of my salary, or the discontinuation of a pre-tax deduction of my salary, on a per paycheck basis as designated above. I understand this election replaces my current HSA election in my payroll account. Furthermore, I understand any withdrawals/distributions from my HSA for non-qualified expenses (for example, health care expenses incurred prior to the establishment of my HSA) will be treated as taxable and may be subject to additional penalties in accordance with IRS regulations. I authorize a pre-tax deduction of my salary, or the discontinuation of a pre-tax deduction of my salary, on a per paycheck basis as designated.Click here to enter text.Click here to enter a date.Print Employee (Account Owner) NameDatePlease Note: Refunds from a HSA are responsibility of the participant and may include fees. Please contact OPTUM Bank for account inquiries.Payroll OnlyPayroll Company: Click here to enter text. ................
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